DRUG INTERACTIONS CNS Drugs 1998 May; 9 (5): 381-401

1172-7047/98/0005-0381/$10.50/0

© Adis International Limited. All rights reserved.

Drug Interactions with

Antipsychotic Agents
Incidence and Therapeutic Implications
Troy L. ZumBrunnen and Michael W. Jann
Department of Pharmacy Practice, Mercer University Southern School of Pharmacy,
Atlanta, Georgia, USA

Contents
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 381
1. Sources of Drug Interactions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 383
1.1 Overview of Pharmacokinetic Interactions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 383
1.2 Overview of Pharmacodynamic Interactions . . . . . . . . . . . . . . . . . . . . . . . . . . . 384
2. Assessment of Therapeutic Plasma Concentrations . . . . . . . . . . . . . . . . . . . . . . . . . . . 384
3. Specific Drug Interactions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 385
3.1 Anticholinergic Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 385
3.2 Anticonvulsants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 386
3.3 Antidepressants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 389
3.4 Antihypertensives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 391
3.5 Antituberculars . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 393
3.6 Anxiolytics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 393
3.7 β-Adrenoceptor Antagonists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 394
3.8 Cimetidine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 395
3.9 Lithium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 395
3.10 Tobacco . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 396
4. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 398

Summary Antipsychotics are the mainstay of treatment for psychotic disorders. Both the
newer atypical antipsychotics and their more traditional counterparts are subject
to drug-drug interactions amongst themselves, with other psychotropics and with
agents used in the treatment of various physical ailments. Furthermore, drug
interactions have been documented to occur with many agents commonly used
in conjunction with antipsychotics such as anticholinergics, anticonvulsants,
antidepressants, anxiolytics and lithium.
Different types of drug interaction can occur, including pharmacodynamic,
pharmacokinetic and pharmaceutic interactions. Pharmacodynamic interactions
occur between agents that have similar receptor site activity.
Pharmacokinetic interactions occur when the combination of drugs results in
alterations in the absorption, distribution, metabolism or excretion of either agent.
As a group, the antipsychotics are highly protein bound (>90%) and distribute
widely into tissues. As a consequence, interactions can arise from combining
antipsychotics with other agents that are also highly protein bound. Antipsychot-
ics undergo phase I and II metabolism to more water-soluble compounds to aid
382 ZumBrunnen & Jann

in excretion from the body. Research has dramatically expanded in the area of
metabolism by the cytochrome P450 (CYP) system. Most antipsychotics are
metabolised by the CYP system and potential drug interactions could occur when
they are administered with other agents that affect or are metabolised by the same
isozymes. Persons who lack specific CYP isozymes (CYP2D6 or CYP2C19) can
be at an increased risk for the development of adverse effects when administered
antipsychotics, due to higher than expected plasma concentrations of these drugs.
The anticonvulsants carbamazepine and phenobarbital (phenobarbitone) are
enzyme inducers. When these drugs are given concurrently with antipsychotics,
decreased plasma concentrations and therapeutic effectiveness of antipsychotics
can occur. Tricyclic antidepressants can compete for similar metabolic enzymes
with antipsychotics. This can result in an increase in plasma concentrations and
a risk of adverse effects of either agent. All clinically available serotonin (5-
hydroxytryptamine; 5-HT) reuptake inhibitors have inhibitory activity at various
CYP isozymes and potentially cause increases in plasma concentrations of anti-
psychotics. Smoking is relatively common in schizophrenic populations and can
induce metabolic enzymes, resulting in lower then expected plasma concentra-
tions of several antipsychotics.
Most data on antipsychotic drug interactions come from case reports and lim-
ited uncontrolled studies, making assessment of the clinical significance of the
interactions difficult. However, with further insight into the metabolic interac-
tions of the CYP isozyme systems through in vitro and in vivo testing, the clinical
significance of these drug interactions will become more apparent.

Antipsychotic agents are used for the treatment
of schizophrenia and other psychotic disorders.
The estimated prevalence of schizophrenia world-
wide is between 0.5 and 1.0%.[1]
Antipsychotics have binding affinity at a variety
of receptor systems including dopaminergic, sero-
tonergic, cholinergic, histaminergic and adrener-
gic. These receptor interactions are responsible for
the therapeutic effect of antipsychotics as well as a
variety of adverse effects and potential drug-drug
interactions.[2] Traditionally, antipsychotics are be-
lieved to work through their antagonistic activity
at dopamine receptors, most notably the dopamine
D2 receptor subtype. Indeed, the antipsychotic po-
tency of these drugs has been measured by their
ability to occupy D2 receptors. The use of clozapine
and other atypical antipsychotics brought new
insight into the pathophysiology of schizophrenia
and the treatment of psychotic disease states. New
antipsychotics have sparked investigation into the
role of other dopamine receptors, most notably D3
and D4.[3] The atypical antipsychotics are so-
named because of their ability to treat psychotic
symptomatology, both positive and negative, and
their minimal potential to cause extrapyramidal
symptoms (EPS) or prolonged elevations in serum
prolactin levels.[4]
Both the typical antipsychotics and the newer
atypical agents are subject to drug-drug interac-
tions. The use of multiple psychoactive agents for
patients with treatment-resistant psychiatric illnesses
or with comorbid psychiatric or physical disease
states has increased the importance of drug-drug
interactions in clinical practice. Unfortunately,
much of the literature pertaining to drug interac-
tions with antipsychotics comes from empirical
case reports and small uncontrolled trials.[5] From
these reports, it may be possible to theoretically
predict drug-drug interactions based on the phar-
macological or pharmacokinetic profiles of these
agents. However, without controlled trials, the
clinical significance of these drug interactions is
questionable.
The aim of this article is to review the available

© Adis International Limited. All rights reserved. CNS Drugs 1998 May; 9 (5)